ACP InternistWeekly

In the News for the Week of April 29, 2014

Highlights

Medical marijuana may help relieve some multiple sclerosis symptoms but has several
safety concerns

Certain forms of medical marijuana can help treat some symptoms of multiple sclerosis
(MS), but they do not appear to be helpful in treating drug-induced movements in Parkinson's
disease, a review by the American Academy of Neurology found. More...

Vitamin D supplementation is not associated with a decreased risk of falls, meta-analysis
finds

Vitamin D supplementation with or without calcium does not reduce falls by a significant
amount, according to a new meta-analysis. More...

Test yourself

MKSAP Quiz: ED evaluation for a painful body rash

A 64-year-old man is evaluated in the ED for a rash that first developed 3 days ago
and has rapidly spread to cover most of his body. He has a history of mild psoriasis,
well controlled with topical corticosteroids, and asthma. One week ago, he completed
a 10-day course of oral corticosteroids for an acute exacerbation of asthma. On physical
examination, more than 90% of his body surface area is erythematous. There are widespread
coalescing erythematous patches and plaques, many with pinpoint pustules coalescing
into lakes of pus. What is the most likely diagnosis? More...

Influenza

In the wake of recent systematic reviews critical of anti-flu drugs, the Infectious
Diseases Society of America (IDSA) has reaffirmed recommendations on use of neuraminidase
inhibitors (NAIs) for treatment of influenza in high-risk patient populations or severe
cases. More...

Men's health

ED is dynamic, associated with modifiable risk factors that may precede other chronic
diseases

Several modifiable risk factors for erectile dysfunction, including obesity, physical
activity, and alcohol intake, were identified by a recent Australian study. More...

From the College

The ACP Quality Champion 2014 Awards were announced at ACP's first annual Quality
Improvement (QI) reception, held at Internal Medicine 2014 in Orlando, Fla., in early
April. The reception was held to celebrate the accomplishments of ACP Quality Connect,
ACP's re-launched national quality improvement network, and to recognize the leadership
of ACP QI champions from around the country. More...

Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen
the winning caption and win a $50 gift certificate good toward any ACP product, program
or service. More...

Physician editor: Daisy Smith, MD, FACP

Highlights

Medical marijuana may help relieve some multiple sclerosis symptoms but has several
safety concerns

Certain forms of medical marijuana can help treat some symptoms of multiple sclerosis
(MS), but they do not appear to be helpful in treating drug-induced movements in Parkinson's
disease, a review by the American Academy of Neurology found.

The review was published in the April 29 Neurology and was presented at the academy's annual meeting in Philadelphia. Thirty-four studies
met inclusion criteria; 8 were rated as Class I.

The review concluded that medical marijuana only in pill or oral spray form can help
treat some symptoms of MS, including spasticity; certain types of pain related to
spasticity, including painful spasms and painful burning and numbness; and overactive
bladder. Most of the studies examined pill or oral spray forms of medical marijuana.
There were 2 studies that examined smoked medical marijuana for treating MS symptoms.
However, the studies did not provide enough information to show if smoked medical
marijuana is effective.

For Parkinson's disease, the review concluded that use of synthetic THC pills likely
does not help relieve abnormal movements that can develop in the late stages of the
disease from the drug levodopa.

The review also noted safety concerns with medical marijuana, including nausea, increased
weakness, behavioral or mood changes, suicidal thoughts or hallucinations, dizziness
or fainting symptoms, fatigue, and feelings of intoxication. There was one report
of a seizure.

The researchers excluded studies that reanalyzed earlier studies, used a single dose
of medication, or had Class IV evidence or unclear information about them. Overall,
1,619 patients were treated with cannabinoids for less than 6 months. Meta-analysis
of simple proportions revealed that 6.9% (95% CI, 5.7% to 8.2%) stopped the medication
because of adverse events, compared to 2.2% who received placebo (95% CI, 1.6% to
3.5%).

A study of patients with MS who smoked cannabis at least once a month showed an increase
in cognitive impairment. Another article showed that patients with MS who used cannabis
were twice as likely to be classified as globally cognitively impaired as those who
did not use cannabis. Some patients who have neurologic conditions may have preexisting
cognitive dysfunction, which may increase their susceptibility to cannabinoids' toxicities.
Moreover, it is especially concerning that a medication that may have an associated
risk of suicide may be prescribed in a population that is already at increased suicide
risk, the reviewers noted. The studies showed that the risk of serious psychological
effects is about 1%.

The review also concluded there was not enough evidence to support using medical marijuana
for motor problems in Huntington's disease, tics in Tourette's syndrome, cervical
dystonia, or seizures in epilepsy.

Vitamin D supplementation is not associated with a decreased risk of falls, meta-analysis
finds

Vitamin D supplementation with or without calcium does not reduce falls by a significant
amount, according to a new meta-analysis.

Researchers performed a trial-sequential meta-analysis to examine whether additional
randomized, controlled trials of vitamin D's effect on falls were necessary. A trial-sequential
analysis is a cumulative meta-analysis that maintains an overall risk of 5% for type
1 error, the researchers noted, thereby reducing the risk for false-positive results
caused by repetitive statistical testing. The analysis included all participants who
fell in an intention-to-treat analysis. The study results were published online April 24 by Lancet Diabetes & Endocrinology.

Twenty randomized, controlled trials involving 29,535 patients were included in the
meta-analysis. Seventeen of the trials were double-blind and placebo-controlled. The
researchers performed a traditional meta-analysis and found that a pooled analysis
showed no effect of vitamin D, with or without calcium, on fall risk. In the trial-sequential
analysis, the effect estimate of vitamin D with or without calcium was within the
futility boundary, indicating that it did not reduce the relative risk by 15% or more.
The authors also performed a sensitivity analysis with a risk reduction threshold
of 10% and a subgroup analysis of vitamin D and vitamin D with calcium with a risk
reduction threshold of 15%; the effect estimate remained within the futility boundary
in both analyses.

The authors noted that the included trials had high statistical heterogeneity between
results and that the trial-sequential design assumes that results of future trials
will be similar to those of existing trials. However, they concluded that fall risk
does not decrease by 15% or more as a result of supplementation with vitamin D, with
or without calcium. "Further clinical trials of the effect of vitamin D supplements
on falls might be difficult to justify," the authors wrote. "At present, there is
little justification for prescribing vitamin D supplements to prevent falls."

The authors of an accompanying comment said that the current study "contributes to the ongoing controversy concerning interventions
to reduce falls in older people." They noted that the study's results question whether
small, underpowered randomized trials can show an effect of vitamin D supplementation
on falls and said that the feasibility of a large trial has yet to be established.
"Until then, we are left with uncertainty about the benefits of vitamin D supplementation
for reduction in fall risk, particularly among vulnerable older people," the comment
authors wrote.

Test yourself

MKSAP Quiz: ED evaluation for a painful body rash

A 64-year-old man is evaluated in the emergency department for a rash that first developed
3 days ago and has rapidly spread to cover most of his body. His skin is painful.
He has a history of mild psoriasis and asthma. His psoriasis has been well controlled
with topical corticosteroids as needed. His other medications are an inhaled corticosteroid,
salmeterol, and albuterol. One week ago, he completed a 10-day course of oral corticosteroids
for an acute exacerbation of asthma.

On physical examination, he appears ill. Temperature is 38.9 °C (102.0 °F),
blood pressure is 118/78 mm Hg, and pulse rate is 112/min. More than 90% of his body
surface area is erythematous. There are widespread coalescing erythematous patches
and plaques, many with pinpoint pustules coalescing into lakes of pus. His mucous
membranes are normal.

Influenza

In the wake of recent systematic reviews critical of anti-flu drugs, the Infectious
Diseases Society of America (IDSA) has reaffirmed recommendations on use of neuraminidase
inhibitors (NAIs) for treatment of influenza in high-risk patient populations or severe
cases.

Two Cochrane systematic reviews on flu relief drugs, which for the first time considered
clinical study reports in addition to published studies, concluded that the medicines
didn't have much impact on the course of symptoms. The reviews were summarized in last week's ACP InternistWeekly.

In response to the reviews, the IDSA published a statement that continues to recommend the drugs' use in specific populations. For example, IDSA
recommends that clinicians start antiviral treatment with oral oseltamivir as soon
as possible for any hospitalized patient with suspected or confirmed influenza and
for any patient with suspected or confirmed influenza who has severe or progressive
illness.

The IDSA statement points out that the Cochrane analysis included both influenza virus-infected
and non-infected persons with influenza-like illness. "Given the specific antiviral
activity against influenza viruses of NAIs, this analytic approach underestimates
NAI treatment efficacy," the statement said.

The IDSA statement also noted that randomized, controlled trials of NAIs in ambulatory
patients with mild illness may not apply to severely ill patients or those at higher
risk for influenza complications. Because there are no randomized, controlled trials
of NAI treatment of hospitalized patients, evidence from the many observational studies
of hospitalized seasonal and pandemic 2009 H1N1 influenza patients should be considered,
the society said. These observational studies have consistently reported that NAI
treatment of influenza in hospitalized patients reduces severe outcomes, including
ICU admission and death, especially when treatment is started within 2 days of illness
onset.

Also, the IDSA statement said, no randomized, controlled trial was sufficiently powered
to evaluate the effect of oseltamivir treatment of outpatients to reduce influenza-associated
complications such as hospitalization or lower respiratory tract infections, which
are rare in healthy individuals but more common in people at higher risk for complications.
Pooled data from randomized trials have demonstrated a reduction in clinician-diagnosed
lower respiratory tract infections requiring antibiotics.

The IDSA also endorses current CDC recommendations, which state that anti-flu medications are an important adjunct to vaccination against
the flu.

Clinical trials and observational data show that early antiviral treatment can shorten
the duration of fever and illness symptoms and may reduce the risk of complications
from influenza, such as otitis media in young children, pneumonia, and respiratory
failure; may reduce mortality; and may shorten the duration of hospitalization, according
to the CDC.

Men's health

ED is dynamic, associated with modifiable risk factors that may precede other chronic
diseases

Several modifiable risk factors for erectile dysfunction, including obesity, physical
activity, and alcohol intake, were identified by a recent Australian study.

Researchers surveyed 810 Australian men ages 35 to 80 during clinic visits 5 years
apart. Erectile function, sexual desire, and sociodemographic, lifestyle, and health-related
factors were examined. Results were published in the May Journal of Sexual Medicine. At baseline, 23.2% of the men had erectile dysfunction (ED), 19.2% had low solitary
sexual desire, and 6.0% had low dyadic sexual desire. All 3 issues were found to be
dynamic: For example, by the end of follow-up, ED had occurred in 31.7% of studied
men, but remission was observed in 29%.

The researchers found several predictors of incident ED, including older age, lower
income, higher abdominal fat mass, low alcohol intake, higher obstructive sleep apnea
risk, voiding lower urinary tract symptoms (LUTS), depression, and diabetes. Age is
a particularly significant factor. For every 10.6-year increase in age, the risk of
ED incidence increases more than 2-fold, the researchers noted. Predictors of remission
included younger age, current employment, absence of voiding LUTS, depression, and
diabetes.

Incidence of low sexual desire was predicted by insufficient physical activity and
low alcohol intake, along with not being married and socioeconomic factors. Remission
was more likely in patients who had lower abdominal fat and higher physical activity,
among other factors, leading researchers to conclude that some risk factors for these
problems are remediable with lifestyle changes.

The finding of an association between lower income and ED risk correlates with previous
findings of more cardiovascular disease in patients of lower socioeconomic status,
the researchers noted. Similarly, associations with angina and diabetes fit with current
understandings of the effect of cardiovascular health on erectile function, the researchers
wrote. The finding of a protective effect from moderate alcohol consumption also fits
with prior research, they noted.

The study also shows that "ED and low sexual desire may precede the development of
many of these abnormalities and should be considered sentinel markers of chronic disease,"
the authors concluded.

From the College

The ACP Quality Champion 2014 Awards were announced at ACP's first annual Quality
Improvement (QI) reception, held at Internal Medicine 2014 in Orlando, Fla., in early
April. The reception was held to celebrate the accomplishments of ACP Quality Connect,
ACP's re-launched national quality improvement network, and to recognize the leadership
of ACP QI champions from around the country.

The awards program was hosted by Bernard Rosof, MD, MACP, chair and CEO of QHC Advisory
Group, and Laura Lee Hall, PhD, director of the ACP Center for Quality, and featured
welcoming remarks by Steven Weinberger, MD, FACP, Executive Vice President and CEO
of ACP. The following leaders were announced as the 2014 ACP QI Champions:

Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen
the winning caption and win a $50 gift certificate good toward any ACP product, program
or service.

E-mail all entries to acpinternist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers.
The winner will appear in an upcoming edition.

MKSAP Answer and Critique

The correct answer is B: Pustular psoriasis. This item is available to MKSAP 16 subscribers
as item 20 in the Dermatology section. More information is available online.

This patient has severe pustular psoriasis. Widespread erythema, scaling, and sheets
of superficial pustules with erosions are the findings associated with severe pustular
psoriasis. Erythroderma, which is present in this patient, is defined as generalized
erythema of the skin involving more than 90% of the body surface area. The most common
causes of erythroderma are drug eruptions, psoriasis, atopic dermatitis, and cutaneous
T-cell lymphoma. Patients who have a history of psoriasis and are treated with systemic
corticosteroids are particularly prone to developing an acute pustular erythrodermic
flare after discontinuation of the corticosteroids. The appropriate management is
to treat the underlying disease (psoriasis in this patient) and provide general supportive
care.

Candida albicans overgrows and causes localized disease in immunocompromised patients or in the presence
of warmth, moisture, maceration, antibiotic therapy, or the use of occlusive garments.
Cutaneous candidiasis is characterized by red, itchy, inflamed skin. At sites of skin-to-skin
contact, lesions have glazed, shiny, and sometimes eroded surfaces and may be characterized
by burning. Satellite pustules (yellow, fluid-filled lesions at the edge of the confluent
red eruption) are another key physical finding.

Sweet syndrome is also known as acute febrile neutrophilic dermatosis. It is more
common in adults than children. The majority (50% to 80%) of patients have a fever.
Arthralgia, myalgia, and arthritis are seen in 30% to 60% of patients. The skin findings
are edematous red-purple plaques on the trunk and extremities. They are often painful
or burning, not pruritic. Sweet syndrome is often considered a reactive syndrome,
associated with a preceding respiratory or gastrointestinal tract illness; an association
with malignancy occurs in about 10% of patients. First-line therapy for Sweet syndrome
is systemic corticosteroids.

Toxic shock syndrome is associated with many different skin manifestations, but the
initial manifestation is typically a diffuse erythroderma resembling sunburn that
involves both the skin and the mucous membranes. Toxic shock syndrome is usually associated
with infection, wounds, nasal packs, or menstruation. This patient has no risk factors
for toxic shock syndrome, and his clinical presentation with erythematous patches
and plaques, pinpoint pustules, lakes of pus, and normal mucous membranes is not compatible
with the diagnosis.

Key Point

Patients with a history of psoriasis who are treated with systemic corticosteroids
may develop an acute pustular erythrodermic flare after the systemic corticosteroids
are discontinued.

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